When is it time to consider surgery in Inflammatory

Bowel Disease

Mark J. Koruda, MD

Department of Surgery

UNC Chapel Hill, NC

Surgery for Inflammatory Bowel

Disease

Timing is everything !

Stack the deck in your favor !

Perioperative Complications with

Crohn’s Disease

•Wound Infections - 2- 37%•Anastomotic Leak - 1-17%•Death - 0 - 7%•Risk Factors

– Intestinal Obstruction– Preexisting sepsis– Impaired nutritional state– ? Immunosuppression– Multiple anatomoses

Surgery for Inflammatory Bowel

DiseaseGet your patient in best possible

condition for surgery•Nutrition – consider intervention

•Albumin <3.0; 5% wgt loss @ 3 mos

• Sepsis – Drain abscess

• Bowel Prep/decompression

• No need to wean steroids/immunes

• Prepare for ostomy

Facts About Surgery

Who Undergoes Surgery?•Patients with symptoms not relieved by

medication•Patients with serious complications, eg,

abscesses, fistulas, intestinal blockage, or uncontrolled bleeding

What Does It Do?•Relieves symptoms •Does not prevent relapse

How Is It Performed?•Usually only a small section of the intestine is

removed, but entire colon may be removed in some cases

INDICATIONS FOR SURGERY IN CROHN’S

DISEASE

Indications for Surgery

Medical Management Failure(34%)

Fistula(24%)

Obstruction(22%)

Mass(12%)

Abscess(7%)

Ann Surg 214:231, 1991

Indications for Surgery

Perianal Disease

Fistula/Abscess

Toxic

Obstruction

Other

0 10 20 30 40 50 60

Small Bowel Ileo-colonic Colon

Surgery for Inflammatory Bowel

Disease

Barium Studies

• +/- Road Map

• Extent of disease

• Avoid with high grade obstruction

• “X-rays lie” and “We don’t operate on x-rays”

Preop Evaluation

Surgery for Inflammatory Bowel

Disease

Colonoscopy:

• Evaluate colonic disease esp distal activity

• Evaluate strictures

Preop Evaluation

Surgery for Inflammatory Bowel

Disease

CT SCAN – esp with mass or fevers

• r/o abscess

• Relation to organs – ureters

• Plan incision

Preop Evaluation

Ureter

PELVIC ABSCESS

PELVIC ABSCESS

Surgery for Crohn’s DiseaseFistulas

• Enteroenteric (EE)- nuisance fistulas do not necessarily require surgery

FISTULAE AND SINUS TRACTS

FISTULAE AND SINUS TRACTS

Surgery for Crohn’s DiseaseFistulas

• Enteroenteric (EE)- nuisance fistulas do not necessarily require surgery

• EEs (duodenocolonic, gastrocolonic, ileosigmoid, jejunocolonic)that cause metabolic, nutritional, output Cxs should be repaired

• Fistulas (ileum or colon) between urinary tract commonly require repair

• Fistulas (ileum or colon) between vagina commonly require repair

SURGICAL OPTIONS FOR INTRA-ABDOMINAL

DISEASE IN CROHN’S DISEASE

Operative Management

Margins of Resection

•Wide margins are unnecessary•Frozen sections unnecessary•Do resect gross disease•Any suitable anastomosis - OK

Laparoscopic Surgery in IBD

• 4 – 6 ports• 5 – 10 cm periumbilcal incision• Cosmetics• Pain• Length of Stay• Recuperation• Anticipate potential future

stoma in incision placement

Laparoscopic Surgery

Crohn’s Disease Indications should not differ between open (conventional) and laparoscopic surgery

Contraindications:• Diffuse peritonitis• Acute obstruction with distension accompanied by dilated loops of intestine• History of multiple previous laparotomies, known dense intra-abdominal adhesions• Coagulopathy not correctable • Portal HTN with intra-abdominal varices

Laparoscopic Surgery

Crohn’s Disease – Bottom Line

• Improved postoperative pulmonary function• Slight reduction in duration of postoperative ileus• Decreased hospital stay (5 v 6 d)• A slight decrease of the cost of direct hospital costs for laparoscopic surgery• A moderate decrease of surgical morbidity (minor)

Hand-assisted Laparoscopic Surgery

(HALS)

STRICTUROPLASTY (HEINEKE-MIKULICZ)

STRICTUROPLASTY (FINNEY)

Non-conventional Stricturoplasty in Crohn’s

Disease

Stricturoplasty

O.K. to do when...

•Diffuse involvement with multiple strictures

•Stricture(s) after previous major resection(s)

•Fibrotic stricture

•Perforated•Phlegmon / fistula•Bleeding•Multiple Strx in short

segement•Strx close to resection site•Colonic Stx (Ileo-colonic OK)•Poor nutrition

Stricturoplasty

Don’t do when...

•Segmental Colectomy•Colectomy - colostomy•Subtotal colectomy -

ileostomy• Ileo-rectal anastomosis

(IRA)

Crohn’s Colitis

High Risk of Recurrence

Fate of the rectum in patients undergoing total

colectomy and IRA for Crohn's disease

Year N 5 yr CR 10 yr CR

Fx IRA 5yr

Fx IRA 10yr

1981 105 70

1984 63 64 71

1990 59 34 49

1992 118 63 86 48

1993 83 47 57 77 63

1997 42 42 74 65

2000 65 86 78

2001 106 47 58 78

2002 144 58 83 86 86

Surgery for Crohn’s Disease

RV Fistulas• Rectovaginal Fistulas – commonly are nuisance

• Upwards of 50% heal with medical management (infliximab)

• Surgical repair - ~70% successful

• Depends on quality of vaginal and rectal disease

• Steroids -> negative effect

Surgery for Crohn’s Disease

RV Fistulas - Surgery

• Transrectal flap – limited by rectal disease/stenosis

• Transvaginal flap

• Transrectal and –vaginal approach

• +/- Diversion – ileostomy vs colostomy

PERIANAL FISTULAE AND ABSCESS

Imaging Perianal Fistula in Crohn’s Disease

Fistulography

Imaging Perianal Fistula in Crohn’s Disease

EUS

Imaging Perianal Fistula in Crohn’s Disease

MRI

Perianal Fistula in Crohn’s Disease- NOT!

Hydradenitis Suppurativa: chronic, recurrent inflammatory process involving the apocrine glands of the axilla, groin, perineal, and perianal regions

SURGICAL TREATMENT OPTIONS FOR PERINEAL

CROHN’S DISEASE

The Surgisis AFP plug is made from a complex collagen (protein) scaffold obtained from pigs—which have a collagen structure almost identical to that of human tissue.

Closure of Crohn's anorectal fistula tracts using Surgisis® anal fistula plug is safe and successful in 80 percent of patients and 83 percent of fistula tracts. Closure rates were higher with single tracts than complex fistulas with multiple primary openings.

INDICATIONS FOR SURGERY IN ULCERATIVE

COLITIS

TOXIC COLITIS

TOXIC COLITIS

PERFORATIONPERFORATION

Fulminant Colitis

• Total abdominal colectomy - ileostomy• Safest operation• 20% of cases

INDICATIONS FOR SURGERY IN ULCERATIVE

COLITIS

RISK OF COLORECTAL CANCER

Stomal Complications...More common than you

think !• 150 ileostomies over 10 yrs with 20 yr

f/u• U.C. - 76%; Crohn’s - 56%

Stenosis(5%)

Prolapse(9%)

Retraction(14%)

Obstruction(20%)

Fistula(8%)

Hernia(12%)

Skin Problem(32%)

Br. J. Surgery 81:727, 1994

IPAA Cases @ UNC (808)

IPAA Stages

Single Stage

• Healthy• No chronic steroids• No chronic immunosupressants• Technically sound• 5% of cases

IPAA Stages

Two Stages(IPAA-ileostomy; ileostomy

takedown)

• Elective operation• Chronic steriods• Chronic immunosuppressants• Technical considerations• 60% of cases

IPAA Stages

Two Stages(Colectomy-ileostomy;

Completion proctectomy IPAA)

• Usually an urgent 1st operation• High dose steroids• Safest 1st operation• IPAA w/o ileostomy if technically sound• 20% of cases

IPAA Stages

Three Stages(Colectomy-ileostomy; Completion

proctectomy IPAA-ileostomy; Ileostomy TD)

• Usually an urgent 1st operation• High dose steroids• Safest 1st operation• Technical considerations -> ileostomy• 20% of cases

Laparoscopic Restorative Proctocolectomy

Cochrane Review 2009

• Eleven trials - 607 patients

• No significant differences in mortality or complications

• Operative time was significantly longer in the laparoscopic group

• No significant differences regarding postoperative recovery parameters.

• Higher cosmesis scores in the laparoscopic group. (smaller incisions)

Laparoscopic Restorative Proctocolectomy

Cochrane Review 2009

Authors' conclusions

• The laparoscopic IPAA is a feasible and safe procedure.

• Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable.

IPAA Complications

Early (30-40%)

• SBO – 10-30% (4x with ileostomy)• Sepsis/Abscess – 3-15%• Thrombotic – DVT, PE, SMV or Portal• Bleeding – GI vs intra-abdominal• Pouch ischemia• Pouch leak

IPAA Complications

Late • SBO – 10-30% (4x with ileostomy)• Pouch Stricture – 8-14%• Pouchitis – 50%• Pouch fistula – 3-10%• Pouch Loss – 1-4% • Hernia

IPAA “Novel” COMPLICATIONS

• Thrombotic complications in IBD - 1% to 6% and as high as 39% in a postmortem study.

• The cause of hypercoagulability in IBD is unclear– Related to activity of disease and

coagulation abnormalities: increased plasminogen activator inhibitor, factors V and VIII, and fibrinogen and decreased factor V Leiden, antithrombin III, proteins C and S

– 60% of pts with active IBD had a hypercoagulable state vs 15% with inactive disease

IPAA “Novel” COMPLICATIONS

• SMV – PV Thrombosis• 45% of pts who had post op IPAA CTs• “The incidence of postoperative SMV-

PV thrombosis is likely more frequent than previously reported. “

IPAA “Novel” COMPLICATIONS

“Pouch Stasis”

POUCHITIS